OMB Control Number: 2060-0170 Expiration Date: 4/30/12

EPA Form # 5900-155, Revised 04/09 

### U.S. Environmental Protection Agency

STRATOSPHERIC OZONE PROTECTION PROGRAM 

### CLASS I CONTROLLED SUBSTANCE

DISTRIBUTOR OF QPS

METHYL BROMIDE QUARTERLY REPORT 

### (Sec 82.13)


## SECTION 1 DISTRIBUTOR IDENTIFICATION

1.2 Total Quantity of Methyl Bromide Delivered for Use in Certified QPS Applications (kg) 1.3 Original Submittal

Re-submittal 1.1 Date of Submission

1.4 Quarter and Year to Which This Report Applies 1 st 

### 2 nd 

### 3 rd 

### 4 th 

### Year

1.5 Distributor Information

Company Name

Street Address

City State Zip Code



### 1.6 Distributor Contact Identification

Reporting Distributor Contact Person Phone Number Fax Number

E-mail Address



### 1.7 Supplier Identification

Supplier Name



### 1.8 Signature of Reporting Distributor Representative

I certify that the total quantity of methyl bromide listed in this form was exclusively sold for use in quarantine & preshipmen t applications, and not sold/ transferred to another person. I certify under penalty of law that I have per sonally examined and am familiar with the information submitted in this and all a ttached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the info rmation, I believe t hat the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false in formation, including the possibility of fine and imprisonment.

Name

___________________________________________________________________

Title

_____________________________________________________________________ Signature

________________________________________________________________ Date

_______________________________________ 

## SEND COMPLETED FORMS TO: For U.S. Postal Service:

Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1200 Pennsylvania Avenue, NW Washington, DC 20460 For Private Courier:

Tracking System Program Manager Stratospheric Protection Division U.S. EPA – (6205J) 1310 L Street, NW; 10 th Floor Washington, DC 20005
Information in reports submitted in compli ance with the final rule may be claimed as confidential. A company may assert a clai m of confidentiality for information submitted by clearly marking that informat ion as confidential. Such information shall be treated in accordance with EPA’s proc edures for information claimed as confidential at 40 CFR Part 2, Subpart B, and will only be disclos ed by the means set forth in the subpart. If no claim of con fidentiality accompanies the report when it is received by EPA, it may be made public wit hout further notice to the company (40 CFR 2.203).

The public reporting and recordkeeping burden for this collection of information is estimated to average 2.4 hours per response . Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any sugges ted methods for minimizing respondent burden, including through the use of automated collection techniques to the Director , Collection Strategies Division, U.S. Environmental Protecti on Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.